PROGRAMME OF RESEARCH ON EVALUATING MODELS OF SERVICE DELIVERY
CALL FOR PROPOSALS FOR EMPIRICAL RESEARCH ON MATERNITY SERVICES: AN EVALUATION OF MIDWIFERY-LED UNITS
As part of its programme of research on evaluating models of service delivery, the SDO Programme wishes to commission research on midwife-led births, both at home and in midwifery-led units. Midwifery-led units include facilities run by midwives either adjacent to, or remote from, a hospital able to provide the range of emergency and support services that will be required should unforeseen complications arise. Midwifery-led facilities remote from immediate specialist support are also know as stand-alone midwifery-led units.
This new call will complement the research currently being undertaken for the SDO Programme by Spiby et al concerning community based support in early labour (see www.sdo.lshtm.ac.uk).
Background
Over the past few years there has been a gradual change in the way that maternity services, particularly intra-partum (birth) care, are delivered in the UK. In the recent past the vast majority of women (over 98%) have delivered their babies in hospitals staffed by midwives, obstetricians and anaesthetists and which were equipped to deal with maternal and neonatal emergencies. More recently, an increasing number of women are giving birth in stand-alone midwifery-led centres or at home. Neither of these settings have immediate access to emergency care, and emergency transfer will be required if in-labour or after-delivery problems arise. This change may accelerate over the next few years, driven by a number of factors which include:
• The recent National Service Framework for maternity services (DH, 2004) which promotes;
- Choice in place and type of birth;
- Normality of birth wherever possible; and - Midwifery-led care whenever possible.
• Consolidation of medical staff into larger hospital units to meet requirements of the European Working Time Directive with closure of some obstetric units
in smaller District General Hospitals which may be replaced by midwife-led units.
• Further development of autonomous midwifery practice.
• Recruitment and retention of midwives.
Whilst the concept of midwifery-led birth care for women who have no identifiable risk factors before delivery has broad support from the DH, NHS, professional and user groups, there are concerns about the lack of evidence of this shift in service provision on the outcomes for both mother and child. A recent review of the existing evidence about birth centre outcomes (Stewart et al, 2004) commissioned by the Maternity Research Group of the National Service Framework for Children, Young People and Maternity Services has recommended that empirical research is urgently undertaken to evaluate the outcomes and costs of home births and all types of midwife-led birth centres.
There is currently a range of different settings for delivery. Because this is an evolving area, agreement on definitions of the particular types of setting has not so far been reached. For example, ‘Birthing Centres’ can encompass anything from a small service based in a converted house, to a larger midwifery-led unit with a much larger number of deliveries and staff. This has meant that making comparisons in outcomes between different settings and establishments has been difficult.
Conceptually, however, and for the purposes of the proposed research, they can be divided into three broad groups:
1 Midwifery-led stand-alone settings
In these settings midwives take the sole professional responsibility for care and there is no immediate access to care from obstetricians, paediatricians and anaesthetists and facilities for investigation and treatment of complications and emergencies (for example blood transfusion and ventilation). Home births, Stand-alone Birthing Centres and Midwifery led centres remote from obstetric units are in this category 2 Midwifery-led stand-alongside settings
In these settings midwives take professional responsibility for care but have rapid access to care as required from obstetricians, paediatricians and anaesthetists and facilities for investigation and treatment in an adjacent unit or building on the same site. Midwifery-led units next to obstetric units and ‘home from home’ units are in this category.
3 Obstetric led settings
In these settings midwives work under the supervision of obstetricians, who take the lead professional responsibility, and have direct access to paediatricians and anaesthetist and facilities for treatment and investigation. Hospital Obstetric units are in this category.
Although there are several examples of popular long-standing midwifery-led units, there has been little formal research concerning the outcomes for their mothers and babies, transfer rates and patient satisfaction.
Current call for proposals
Before the DH can fully endorse an accelerated change towards offering the choice of midwifery-led units, it is vital that a well constructed prospective study be undertaken that can provide information about a range of issues. This study should build on the work of the National Perinatal Epidemiology Unit on birth centre outcomes referred to above (Stewart et al, 2004).
The SDO Programme is now calling for proposals to undertake research on midwifery-led units which will address the following questions:
1 Definitions
• What are the most useful definitions and terms to describe the different settings of delivery?
• How can these terminologies be standardised?
2 Capacity
• What is the likely proportion of women who will deliver in stand-alone (including home births) or stand-alongside midwifery units?
• What type and number of units are likely to be developed?
• How will issues concerning midwifery recruitment and retention affect development of different settings of delivery?
• How will implementation of the European Working Time Directive (and forthcoming 48 hour target for junior medical staff) influence the development of different settings of delivery?
3 Safety and costs
• Is promoting this policy safe for women and their babies (even for women considered at low risk of encountering problems during labour)?
• What are the maternal and child outcomes for the different types of care?
• What is the comparative cost effectiveness of each type of care?
4 Transfer
• What proportion of mothers and babies require transfer during labour or after birth from home, or a stand-alone or stand alongside midwifery led setting to an obstetric led setting?
• How long do transfers take and is this acceptable in terms of safety?
• How can safe and effective transfer be ensured?
5 Satisfaction
• What are the comparative levels of user satisfaction between the different settings of delivery?
• Does this vary according to the type of setting or does it vary more between individual units within a type of setting?
• Is transfer generally acceptable to women?
• What length of transfer is acceptable to women?
6 Accessing Choice of Setting of Delivery
• Is it practical and desirable to have a full range of different settings of delivery available to every woman in England?
• How can we ensure that women are given informed choice about the setting of delivery?
• How should women make different choices about setting of delivery (for example should this be self referral, through GPs, or should it be Midwifery led)?
• How do we ensure that women from vulnerable groups such as black minority ethnic groups are given appropriate choices?
7 Commissioning choice
• How should different settings of delivery be commissioned and how does this link to the development of practice based commissioning?
Study design and methods
Applicants should provide a full description of the study design they propose, together with the methods they would use to address each of the above issues. The study will require both quantitative and qualitative perspectives. Applicants should demonstrate that they have the capabilities to undertake both of these aspects and, where appropriate, integrate between them.
Applicants should indicate the timing of their research in respect of each of the above questions. It may be possible to obtain answers to questions 1 and 2 (concerning definitions and capacity) more quickly than the others (possibly within a year). Under these circumstances an interim report in respect of those findings will be required.
Involvement of stakeholders and co-operation with policy makers
To provide a comprehensive maternity service it is vital that policy makers, commissioners, all groups of health professionals, and service users work in partnership. In order for this research to be useful, it is essential that the study is performed by a muti-disciplinary group representative of all parties. Applicants should demonstrate how they will achieve this.
The National Institute for Health and Clinical Excellence (NICE) is in the process of producing guidelines about intrapartum care (entitled ‘Intrapartum care: management and delivery of care to women in labour’), and the results of this SDO commissioned research will make a vital contribution to those guidelines. Successful applicants will therefore be required to liaise closely with NICE and their National Collaborating Centre for Women’s and Children’s Health.
Outputs
The SDO Programme is interested in ensuring that all projects produce a variety of outputs of practical use to diverse stakeholders. Outputs from this project should include:
• A plain language executive summary (maximum 2000 words) suitable for wide dissemination across the NHS.
• A main project report with supporting technical appendices suitable for academic peer review.
• Academic peer-reviewed outputs.
Additionally, applicants should indicate how they will work with the SDO Programme and relevant stakeholders to build-in an active programme for disseminating their research findings in policy, practice and research contexts.
References
Stewart, M., McCandish, R, Henderson, J. and Brocklehurst, P. (2004) ‘Review of the evidence about clinical, psychosocial and economic outcomes for women with straightforward pregnancies who plan to give birth in a midwife-led birth centre, and outcomes for their babies’ National Perinatal Epidemiology Unit, Oxford
Department of Health (2004) National Service Framework for Children, Young People and Maternity Services Department of Health, London
Application process and schedule
The research call is for a single empirical study.
Applicants must submit proposals using the Full Proposal Application Form, which is available as a Word 97 file or Rich Text format from:
• the SDO website: http://www.sdo.LSHTM.ac.uk/calls.htm, or
• by Email from: [email protected]
It is important that you do not use any previously obtained version of an SDO Programme application form as the application form has changed.
To ensure the efficient and equitable answering of additional queries, all questions about this research call should be sent by e-mail only to [email protected] with the words ‘BC133 query’ in the subject/header.
Questions received by 13 October 2005 will have generic answers posted on the SDO website (www.sdo.LSHTM.ac.uk) by 20 October 2005.
Applicants are asked to submit proposals by Thursday 17 November 2005 at 1.00 pm to:
Donna Cox
Commissioning Manager NCCSDO
London School of Hygiene and Tropical Medicine 99 Gower Street
London WC1E 6AZ
AN ORIGINAL PLUS TWENTY-FIVE HARD COPIES of the completed Full Proposal Application Form should be submitted together with a copy on disk or CD. Please note we will not accept electronic submissions or hand written proposals.
No late applications will be considered..
Guidance notes for the completion of the Full Proposal Application Form can be found at the front of the application form.
Funding of a maximum of £400,000.00 is available for funding one project in this topic area. Applicants should note that value for money is an important consideration in respect of this research. Proposed costs of the project should not exceed the limits stated above. NHS R&D Programmes are currently funding Higher Education Institutions (HEI) at a maximum of 80% of Full Economic Cost (except for equipment over £50,000 – 100%). For non-HEI institutions, NHS R&D may fund 100% of costs. However, the SDO Programme reserves the right to award a grant for less that this maximum where appropriate.
Following submission of full proposals successful applicants will be notified no later than February 2006. The project should take no longer than 3 years to complete and start no later than May 2006. Please note that these dates are approximate and may be subject to change.
The SDO Programme will look favourably on proposals that include an element of research capacity building.
In addition, applicants should indicate how they will work with the SDO Programme and relevant stakeholders to build in an active program for disseminating their research findings in policy, practice and research contexts.
Please clearly label the outside of the envelope in which you submit your proposal with the following: ‘Tender Documents BC133’. This will enable us to identify proposals and keep them aside so that they may all be opened together after the closing date and time.
Teams should ensure that their proposal complies with the Research Governance Framework, which can be found on the Department of Health website, or via a link on the SDO website under the ‘Call for Proposals’ page.
Before funding, successful teams will be required to provide proof of research ethics committee approval for their project, if this is required (information regarding this can be found on the SDO website under the ‘Funding opportunities & commissioning processes’ page).
We anticipate that there will be informal discussions with NCCSDO throughout the duration of the project regarding the final report.
Applicants should visit the SDO website: http://www.sdo.lshtm.ac.uk to familiarise themselves with the work of the SDO Programme in general and with previous commissioning in other topic areas.
Addendum
This document was published by the National Coordinating Centre for the Service Delivery and Organisation (NCCSDO) research programme, managed by the London School of Hygiene & Tropical Medicine.
The management of the Service Delivery and Organisation (SDO) programme has now transferred to the National Institute for Health Research Evaluations, Trials and Studies Coordinating Centre (NETSCC) based at the University of Southampton. Prior to April 2009, NETSCC had no involvement in the
commissioning or production of this document and therefore we may not be able to comment on the background or technical detail of this document. Should you have any queries please contact [email protected].
